Author Affiliations: Marcella Niehoff School of Nursing, Loyola University Chicago (Dr Oosterhouse, Ms Young, Ms Desai, and Dr Bobay); Capital Planning, Loyola University Chicago (Mr Birch); and Office of Strategy and Innovation, Loyola University Chicago, IL (Mr Price).
Comput Inform Nurs. 2021 Apr 22;39(9):471-476. doi: 10.1097/CIN.0000000000000710.
Delirium, an acute mental status change associated with inattention, confusion, hypervigilance, or somnolence due to a medical cause, is considered a medical emergency. Unfortunately, screening and diagnosis of delirium in acute care are often inadequate. It is estimated that 60% of delirium cases are not identified, and in claims data, they are underreported. Using information technology, we investigated whether concept unique identifiers from the Unified Language Medical System Metathesaurus could be used as a method to filter electronic health records for possible delirium cases. This article provides the reader with an overview of delirium, the Unified Language Medical System Metathesaurus, and our method for retrospectively filtering electronic health records for delirium cases from our clinical research database. Using a retrospective observational approach, we randomly selected 150 electronic health records with narrative notes containing a delirium concept unique identifier. One hundred records were used for training and 50 were used for validation and interrater reliability. Our results validate electronic health record-selected concept unique identifiers and provide insights into their use. Refinement and application of this method on a larger scale can provide an initial filter for identifying patients with delirium from the electronic health record.
谵妄，一种与注意力不集中、意识混乱、过度警觉或因医学原因引起的嗜睡相关的急性精神状态改变，被认为是一种医疗紧急情况。不幸的是，急性护理中谵妄的筛查和诊断往往不足。据估计，60%的谵妄病例未被发现，在索赔数据中，它们的报告不足。我们利用信息技术研究了统一语言医学系统术语表中的概念唯一标识符是否可以用作从电子健康记录中筛选可能的谵妄病例的一种方法。本文为读者提供了谵妄、统一语言医学系统术语表以及我们从临床研究数据库中回顾性筛选电子健康记录中谵妄病例的方法概述。我们采用回顾性观察方法，随机选择了 150 份包含谵妄概念唯一标识符的有叙述性记录的电子健康记录。其中 100 份记录用于培训，50 份记录用于验证和内部评估者间可靠性。我们的结果验证了电子健康记录中选择的概念唯一标识符，并提供了对其使用的深入了解。在更大的范围内对这种方法进行改进和应用，可以为从电子健康记录中识别出患有谵妄的患者提供一个初步的筛选器。
